question of how we ought to assess costs, efficacy, or the balance between them. Should oncologists be concerned about the costs of two efficacious treatments that are roughly equal, where one is far more expensive than the other? What about two treatments that have discernible but modest differences in efficacy and substantial differences in costs? As Smith and colleagues have wryly noted, “If oncologists do not work to determine the efficacy and cost effectiveness of cancer treatment, others will do it for them” (Smith et al., 1993). Of course, it may be that oncologists should insist upon others doing this work. Perhaps societal or personal values are what should matter, and oncologists may have no special insight into these matters. Either way, we have no method by which to weigh these issues and to implement any ensuing judgments.

Even defining “cost” turns out to be a difficult endeavor. It cannot be confined to the costs of the particular treatment modality because each treatment has side effects and toxicities and may require different settings for treatment or for living. Yet, to date most research has focused on the cost of medications and insurance-covered medical care.

The many physical, emotional, and financial burdens families take on when caring for loved ones are beginning to be noted in counting costs. The metric for measuring the subjective components of caregiver burdens is quite unsettled. The complexity of human situations seems hard to capture in a single scale that would allow comparisons, for example, of the burdens incurred by an elderly wife caring alone for her aged husband who is dying slowly of metastatic prostate cancer with the burdens felt by a large extended family supporting a younger man dying with very difficult suffering from lung cancer.

Smith and colleagues pose the question of whether palliative cancer care can be cost-effective, at least as that is now operationally defined. For many cancers, palliative therapy may be as expensive as chemotherapy (Smith et al., 1993). However, the end points for palliative therapy, although definable in terms of symptom control and quality of life, are not easily quantified. Hillner and colleagues (2000) believe that the recurring challenge for both cancer and noncancer therapies is to establish the financial value of new medical interventions that are not associated with improved survival.

Paucity of Attention to Costs or Quality of Life in Clinical Trials

Until recently, the gold standards for determining the efficacy of a cancer treatment in a clinical trial have been improved survival, tumor shrinkage, and ultimately, cure. As more costly treatments enter the picture, more attention is being given to the economics of cancer therapies. In addition to the absolute costs of the treatments themselves, increasing num-



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